Surgical referral systems in low- and middle-income countries: A review of the evidence

Background: Referral networks are critical in the timely delivery of surgical care, particularly for populations residing in rural areas who have limited access to specialist services. However, in low- and middle-income countries (LMICs) referral networks are often undermined by systemic inefficiencies. If equitable access to essential surgical services is to be achieved, sound evidence is needed to ensure efficient patient care pathways. The aim of this scoping review was to investigate current knowledge regarding inter-hospital surgical referral systems in LMICs to identify the main obstacles to their functioning and to critically assess proposed solutions. Methods: MEDLINE, EMBASE and Global Health databases and grey literature were systematically searched to identify relevant studies. The search generated 2261 unique records, of which 14 studies were selected for inclusion in the review. The narrative synthesis of retrieved data is based on a conceptual framework developed though a thematic analysis approach. Results: Multiple shortages in surgical infrastructure, equipment and personnel, as well as gaps in surgical and decision-making skills of clinicians at sending hospitals, act as obstacles to safe and appropriate referrals. Comprehensive protocols for surgical referrals are lacking in most LMICs and established patient pathways, when in place, are not correctly followed. Interventions to improve coordination and communication between different level facilities may enhance efficiency of referral pathways. Strengthening capacity of referring hospitals to manage more surgical conditions locally could improve outcomes, decrease the need for referral and reduce the burden on tertiary facilities. Discussion: The field of surgical referrals is still an uncharted territory and the limited empirical evidence available is of low quality. Developing strategies for assessing functionality and effectiveness of referral systems in surgery is essential to improve access, coverage and quality of services in resource-limited settings, as well as overall health systems performance.